Job Description

Oversees the efficient and cost-effective functioning of the Medical Records Department at American Hospital Dubai. This includes but is not limited to ensuring the confidentiality and security of patient information, as well as the development, implementation, and maintenance of department policies and procedures. Directs the content and format of the hospital's medical records, as well as medical transcription services and release of information services. Additionally, manages the staff planning, recruitment, evaluation, and development. Ensures the implementation of and compliance with Joint Commission International (JCI), Dubai Health Authority (DHA), and hospital quality standards.

Administrative:

• Ensures that the department's mission and vision reflect and support the mission and vision of the hospital
• Ensures that the department is customer-focused and responsive to the needs of the American Hospital Dubai.
• Ensures that the department meets all set objectives within the relevant timescales.
• Provides leadership and promotes a proactive and motivated department of appropriately skilled staff who are committed to delivering a consistent and high-quality service to both patients and healthcare users.
• Oversees the annual department operational and capital budgets.
• Ensures that all department functions comply with the Joint Commission International Accreditation (JCIA) and hospital quality standards.
• Contributes to the development and implementation of strategy and action plans that support the effective management and delivery of clinical information.

Human Resources:

• Selects and recruits appropriate staff as required; to ensure an efficient service.
• Develops and updates staff job descriptions.
• Oversees the staff scheduling and vacation planning.
• Ensures staff participation in hospital orientation and attendance at all hospital-required in-services.
• Ensures that department-specific orientation and training is provided to all new staff of all grades tailored to the individual and relevant to their area of work.
• Organises training and orientation, as and when required, for any new equipment/ software installed or new processes introduced.
• Develops, maintains, and revises the departmental orientation and competency program.
• Takes action, as required, concerning staff discipline, grievances, poor performance, and sickness as per the American Hospital Dubai's policies.

Health Information Management:

• Ensures the standardization and quality of all patient records and interdepartmental forms.
• Oversees the coordination of and minute-taking for the Health Information Management (HIM) Committee in conjunction with the Medical Chair.
• Attends and supports, as the Health Information Management (HIM) Representative, other hospital committees as invited.
• Maintains a comprehensive and up-to-date knowledge of Joint Commission International Accreditation (JCIA) especially those standards relevant to the Management of Information processes, requirements, revisions, and surveys.
• Directs the accurate compilation and appropriate usage of department workload statistics.

Patient Information:

• Ensures that all patient medical records, whether paper or electronic format, comply with Joint Commission International Accreditation (JCIA), Dubai Health Authority (DHA), and hospital standards; supporting patient information that is legible, accurate, and timely.
• Manages the incomplete records process and reports results, such as deficiency rates, to the appropriate departments and committees.
• Ensures the accuracy, timeliness, and quality of all transcribed medical documents.
• Ensures that the release of patient information complies with the patient’s Rights and Responsibilities, Dubai Health Authority (DHA)and UAE's legal requirements, and American Hospital Dubai's policies.
• Ensures that all patient-related information is retained for the specified timescale; and is archived and disposed of in compliance with the Dubai Health Authority (DHA) and UAE's legal requirements.
• Facilitates the provision of medical record copies and vital statistics to the Dubai Health Authority (DHA) as per requirements.
• Supports and participates in external audits as required.

Training and Awareness:

• Orients all new hospital staff to the Medical Record Department, and the standards required for confidentiality and security of patient information and other hospital-related information.
• Orients all clinical staff to the medical record document obligations, including documentation guidelines, quality requirements, dictation instructions, and transcription services.
• Supports the General Orientation by providing a session on Confidentiality.
• Supports the annual mandatory education by reviewing and updating the Confidentiality online session.
• Ensures support is available to all clinical staff who are required to complete deficient records.

Policies & Procedures:

• Maintains confidentiality policies.
• Develops, implements, and maintains department policies and procedures and implements relevant hospital policies.
• Ensures awareness of and compliance with relevant Dubai Health Authority (DHA) and other regulatory authority standards.
• Supports the investigation of Medical Record Department-related incidents and complaints.
• Oversees the performance of patient record audits and appropriate reporting of results.
• Develops, reports, and audits department-specific key performance indicators (KPIs).
• Ensures that the physical attributes of the department are maintained according to the hospital’s environment of care and safety manual.
• Ensures that all department equipment is functioning safely and adequately.
• Ensures the ongoing review and development of processes to maintain and improve performance and support compliance with quality standards.
• Performs all duties in a professional, effective, and confidential manner.
• Ensures that all hospital staff, patients, and visitors are treated in a welcoming and courteous manner.
• Ensures that all internal and external customer complaints are handled in a timely, courteous, and positive manner.
• Develops and maintains good working relationships with internal and external customers.
• Functions as the facilitator for hospital education and customer service programs.

• Bachelor's Degree in Health Information Management
• Membership of a relevant internationally recognized professional association

PROFESSIONAL EXPERIENCE:

• Minimum of five (5) years of experience in a Medical Records Management capacity in an acute care facility of 100 beds or more.
• Knowledge of Joint Commission International Accreditation (JCIA) standards.
• Skills in Microsoft Office and Hospital Information Systems (HIS).
• Ability to train and develop staff.
• Previous Middle East experience preferred.